Infection control training for CNAs: the steps that slip

Ask any aide when to clean their hands and they'll answer correctly. Infection control training for CNAs has a harder job: making sure they actually do it ten seconds later, walking out of one room and into the next with three call lights on, which no written quiz can see.

International Infection Prevention Week runs October 19 to 25 this year, under the theme "Generations of Infection Prevention," according to APIC, which organizes it. For a community college instructor or a facility's staff development coordinator, it's a good week to look past the sign-in sheet and at the few steps that fall away when a shift gets busy.

Under 42 CFR 483.80, a nursing facility "must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections." The program's written policies have to cover, among other things, standard and transmission-based precautions and "the hand hygiene procedures to be followed by staff involved in direct resident contact." Linens get their own line: "Personnel must handle, store, process, and transport linens so as to prevent the spread of infection."

The training side sits in 42 CFR 483.95(e): infection prevention and control training is mandatory and has to include those written standards, policies and procedures. For aides, the same section sets at least 12 hours of in-service a year, which must "address areas of weakness as determined in nurse aides' performance reviews." We laid out how to spread those hours across the year in CNA in-service training: a year-round plan for the 12 hours.

The federal text doesn't prescribe a format. A slide deck and a sign-in sheet document that training happened; they can't show whether the steps below happen at 7 p.m.

Each of these has an official reference you can put in front of a class, and each is easy to drop when time is short.

• Hand hygiene between residents. The CDC's hand hygiene guidance lists "immediately before touching a patient" and "after touching a patient or patient's surroundings." The second moment is the one that slips. A bed rail, the overbed table or the call light all count as surroundings, and an aide who only touched the room can walk out without cleaning their hands.
• Hand hygiene around gloves. The same page is blunt: "Gloves are not a substitute for hand hygiene." Hands get cleaned before gloves go on and "immediately after glove removal." The usual shortcuts are one pair of gloves stretched across two tasks, or gloves off and straight on to the next thing. When sanitizer is used, the CDC says to rub until hands feel dry, which "should take around 20 seconds."
• The order for putting on PPE. The CDC's PPE sequence poster goes gown, mask or respirator, goggles or face shield, then gloves, which "extend to cover wrist of isolation gown." Gloves first and the gown pulled over them is the common shortcut, and it leaves the wrist open.
• The order for taking it off. The poster gives two safe sequences, both ending in hand hygiene, and the same instruction: "Remove all PPE before exiting the patient room except a respirator, if worn." Its footer is the line to drill: "Perform hand hygiene between steps if hands become contaminated and immediately after removing all PPE." The slips are touching the front of the mask, taking the gown off in the hallway and skipping that last hand cleaning.
• Soiled linens held against the uniform. The CDC's laundry recommendations say to "handle contaminated textiles and fabrics with minimum agitation" and to "bag or otherwise contain contaminated textiles and fabrics at the point of use." On a busy unit the sheet gets shaken out, bundled in the arms and carried down the hall against the scrubs.

In nursing homes the gown comes out well beyond isolation rooms. The CDC's Enhanced Barrier Precautions call for gown and gloves during high-contact care such as dressing, bathing, transferring, providing hygiene and changing linens, for residents with a multidrug-resistant organism or with wounds or indwelling devices. That puts donning and removal into an aide's ordinary routine several times a shift.

A return demonstration during orientation shows an aide can do the sequence once, with an instructor watching and nothing else going on. What makes the steps happen on the floor is repetition spread over weeks, plus somebody who checks the order step by step. In practice that means four habits for whoever runs the training.

• Practice the sequences on their own, often and briefly: a few minutes of donning and removal at the start of each skills session, scored step by step.
• Check hand hygiene inside every other skill. On the unit it happens in the middle of feeding, transfers and perineal care, so that's where it should be graded.
• Watch on the unit during a real shift and give feedback on the spot, pointing to the poster or the CDC moment as the reference.
• Write down which step was missed, by whom and when. Those notes are what 483.95(g) means by areas of weakness, and they tell you what the next in-service block should cover. If you're building CNA orientation from scratch, put PPE and hand hygiene in the first days, before the new aide shadows anyone.

The hard part is the repetition. Each round of donning and removal uses up supplies and an instructor's attention, and running it inside a busy facility pulls staff off the floor.

An aide in a gown and gloves for routine care may have to explain why to a confused resident, every time, and that conversation can be rehearsed too. Watching aides on the unit stays the final check; simulation is how they get enough repetitions to pass it.